Accreditation Looms: Industry Waits on CMS

What You Need to Know & What You Need to Do Next

Sep 01, 2006

Quick quiz: What's your definition of early summer? Your answer probably wasn't August was it? Well, as of Aug. 1, the only component of accreditation that the Centers for Medicare & Medicaid Services (CMS) had moved forward on is the published final rule of the accreditation standards. That's not much considering that CMS said the long-awaited quality standards would be announced in early summer, and considering the expectation that providers need to be accredited by January 2007.

Although providers can work closely with accrediting bodies to get a jump-start on accreditation, the accrediting bodies need the quality standards in order to move forward with applying for Medicare Deemed Status. Without Medicare Deemed Status, accrediting bodies cannot accredit DMEs. Many industry members hope the final rule is a sign that the quality standards are soon to follow.

"I hope the displayed version of the accreditation standards is a preamble of what's to come," says Sandy Canally, R.N., CEO and president of The Compliance Team, Ambler, Pa.

You may not be one of the 10 MSAs, but do you really want to wait until thousands of providers are ahead of you?

According to CMS, the new quality standards will "reflect core good business practices, product specific services designed to ensure that beneficiaries receive the right equipment, training and education to meet their needs."

The rule directs accreditation organizations to consider previous accreditation, Medicare certification and licensure that would indicate that quality standards are being met. CMS will instruct accrediting agencies to focus first on suppliers in the initial phase of the competitive bidding program, but at press time, CMS has not formally released the 10 metropolitan statistical areas where competitive bidding will roll out in 2007.

While providers have repeatedly been told to select an accrediting body and get prepared for accreditation ahead of time, with many essential components of accreditation missing, many providers are not seeing a sense of urgency.

"Providers have nothing to lose if they sign up now; they will be prepared for whatever comes down the pike," says Canally. "Come January or February or whenever when CMS comes out with the approved accrediting bodies, if providers have already prepared, they will be ready as opposed to waiting when thousands of providers could be ahead of them. That's my greatest fear and that's why I get people to sign up now. You may not be one of the 10 MSAs, but do you really want to wait until thousands of providers are ahead of you? We are seeing an increase in people accessing the Web site, but there's still that hesitation and it's not where it should be right now," Canally says.

Once CMS publishes the quality standards, all of the accrediting bodies will review the standards to incorporate them into their current standards. After the standards match, they will apply for Medicare Deemed Status and once that happens, focus first on providers in the 10 MSAs —that is, once those MSAs are formally announced.

Accreditation Companies Seek Stamp of Approval First

CMS will release criteria in an application for all of the accrediting bodies to fill out and submit. The likely accrediting agencies will include the Accreditation Commission for Health Care Inc. (ACHC), the Community Health Accreditation Program (CHAP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), The Compliance Team, the Healthcare Quality Association on Accreditation (HQAA) and ABC/BOC, the prosthetics and orthotics group.

Canally explains, "We will receive the quality standards and maybe say, 'In the area of patient services —we already have everything CMS has published for the quality standards and we exceed it. However, in administration, they now want to see a budget or some financial information from the provider,' in which case we would add any information that wasn't already currently in our standards to comply with CMS's standards. So, there may be some additions, but there wouldn't be any deletions because we —nor would any other accrediting body —delete standards.

Most accrediting agencies only anticipate minor tweaks to their current standards here and there.

"Basically we are going to have to give CMS everything on how we do things, our administrative policies, our standards, our scoring. Not that they don't already have that, because they do. They got that back in 2004 —they got everyone's standards, prior to the initial implementation of the Medicare Modernization Act," says Canally.

Safley doesn't think it will take long for ACHC to receive Medicare Deemed Status. "Since we already have deeming authority for the home health portion of our business, we feel this should not be a long process for CMS to review our qualifications and render a decision on our application for HME deemed status."

The accrediting agencies will be up held to standards much like their own customers. "We are going to submit an application, and CMS is going to come to our office and evaluate us much like we evaluate providers. That's how I look at it, the same kind of thing," Canally says. "They are going to determine if we are meeting their criteria, and the most important thing is how we have our providers meet the quality standards."

Why Providers Should Prepare Now

Providers should not put off accreditation on a technicality. Accrediting agencies already have quality standards in place that closely resemble the quality standards CMS will release. Most accrediting agencies only anticipate minor tweaks to their current standards here and there.

"Although we realize some modifications to our accreditation standards may be needed after the quality standards are released, organizations that are already accredited by ACHC will be well ahead of other non-accredited organizations in meeting CMS requirements," Safley says.

Canally said that some providers can get through accreditation in as little as four months, a timeframe she refers to as "very aggressive."

"We basically assign them an adviser, and that adviser helps them prepare for the process by scheduling conference calls to discuss various items, such as the standards for human resources, what you are going to need in your file, etc. We basically hold their hand and help them through it ourselves so there is no need to spend more money to hire an additional consultant to help them."

All of the accrediting agencies have different tools to assist providers including preparation CDs, manuals, accreditation checklists, online tutorials as well as advisers or consultants.

Safley advises DME suppliers to visit ACHC's Web site to view its pre-survey checklist of likely standards and to order its accreditation manual. "We tell companies that they should not let the manual overwhelm them, but merely use it as a guide for developing their policies and procedures. Most companies, in fact, have these policies in place already and follow them in practice," he says.

At The Compliance Team, once the provider is ready for an on-site evaluation, staff goes on-site to do the evaluation. "At that point, they start sending us patient satisfaction data for us to aggregate and we send out quarterly reports. We do a 60-day follow-up call to make sure they have put corrective action plans in place, and then a year later we are back out there evaluating on-site again," Canally says.

"We feel that if they focus on what matters most to the patient, which we believe is safety, honesty and caring —if they excel in those three areas, what else matters?" Canally says.

Is Medicaid Peeking at What Medicare Is Doing?

How CMS implements accreditation with Medicare is likely to be followed by state Medicaid programs.

"In the state of Pennsylvania, the state Medicaid system actually put out a draft request for proposal (RFP) in June for selective contracting for any DMEs that want to bill Medicaid for state Medicaid (not managed-care Medicaid)," Canally says. "What they required —and obviously they are following in line with CMS and competitive bidding —is an RFP that they all become accredited. So you can see, Pennsylvania has talked about how this is going into place and possibly being effective in the fall, but I don't think that is going to happen in that timeframe."

According to Canally, a lot of details have to be worked out before states can follow suit with what CMS is doing.

"I believe that if this goes through in Pennsylvania, our neighbors New York and Ohio will follow. Pennsylvania is basically trying to take the lead. This is all about the government trying to save money," Canally says.

When it does occur, it stands to dramatically affect small businesses and patient access. "They are going to narrow the number of providers; they were even talking about having 15 providers for the entire state of Pennsylvania," Canally says. "When you get into the very rural areas of Pennsylvania, and they are talking about three per region, that is nuts. However, at this point, it is a draft and we don't know."

Safley agrees that state Medicaid programs will follow suit. "There are some states that will require accreditation. We believe most will follow the same rules for accreditation; however, we cannot speculate as to the timeframe when each state will implement the accreditation requirement."

Many people fear that Medicaid programs that emulate Medicare will hurt the small business provider by scaling down the playing field and restricting access to the end user. "Whether you call it competitive bidding, selective contracting —whatever it is called at the end of the day —I look at it as restrictive care," Canally says.

"These small business providers are essentially serving the community. They are the foundation of the community as it relates to serving wheelchairs and lift chairs and so forth," Canally says. "Certainly they are the backbone of what has built this very industry. Competitive bidding or selective contracting certainly stands a good chance of hurting that, hurting the relationship between the provider and Mrs. Jones …It is almost like people want to save money and so forth, but at the end of the day, what are they really saving? OK, limit the number of providers in a community and then have those patients go to the hospital ER. It is also an atrocity as it relates to the very survival of small business."

When it comes to CMS saving money, Canally says CMS should look at the very costs they are incurring as a result of the MMA. "All of the consulting firms that have been secured, all of the administrative costs internally, let alone externally," Canally says.

The good news is that accreditation will enhance the level of care in the industry and give the industry a better view from the outside, but "restrictive contracting is not the way to do it," Canally says.

Additional Benefits to Becoming Accredited Beyond Billing Medicare

Some of the benefits of becoming accredited include evaluating and improving current business systems, developing customer trust, creating a solid foundation for future growth, enhancing team awareness, improving efficiency and sales, as well as improving patient outcomes.

"Obviously these companies have to have a healthy bottom line, but at the end of the day, the most important thing is to better serve your patients. We are looking at it from a standpoint of patient problems, not waiting until there is a patient problem and then responding. That makes a difference right there," Canally says.

In addition to improved patient outcomes, the educational component of accreditation helps everyone involved. "The person that is delivering and doing the instruction needs to have the training and the qualifications to be able to do the proper assessment to identify that there are issues in the home or issues with the patient not understanding," Canally says.

"The goal of our accreditation model is to help companies become better managers," Safley says. "We truly believe we can better assist our customers to improve their own operations."

The bottom line is that accreditation improves overall business practices.

What's Next?

Industry members say the timeline for providers to be accredited by Jan. 1 is unrealistic with no quality standards in place and accrediting agencies still needing time to prepare for and apply for Medicare Deemed Status.

"CMS must grandfather all current accepted organizations that are accredited by the five national accrediting bodies," Canally says. "In the proposed rule, there was a clause about grandfathering. CMS recognizes that the timeline is such that it is unrealistic to think anyone is going to have deemed status by Jan. 1. If the accrediting bodies don't have an application to even complete until sometime in September, one has to look at it and say, 'Realistically speaking, how is [CMS] going to evaluate us and go into the field and evaluate some of our customers? It is unrealistic that they are going to be able to do that prior to Jan. 1. The only answer is grandfathering."

Regardless of any impending deadlines, accrediting agencies are advising providers to get ready now. "Obviously, there is a train wreck coming or what I like to refer to as a runaway train," Canally says. "And we don't know where it is going to crash and what effect it is going to have."

"Signing up with any of the five nationally recognized accrediting bodies will give providers a sense of comfort because I really think the grandfathering is going to happen because of the reality of the timetable in front of them," Canally says. "We don't want providers to wait."

Do Physicians, Pharmacists and Surgeons Have To Take the Accreditation 'Test?'

"The simple answer is 'yes.' As it stands today, any provider that is billing Medicare Part B will have to become accredited," Accreditation Commission for Health Care's Timothy Safley says. Any provider that bills Medicare for DME and supplies diabetic supplies will in fact have to meet quality standards and will be affected by the MMA.

"The physicians have the American Medical Association (AMA) and very powerful groups behind them," The Compliance Team's Sandy Canally says. "Certainly the pharmacists have some groups that have been very vocal. And the DMEs have AAHomecare, and they have been very vocal, with lots of grassroots lobbying that is taking place, but do we have the power and the weight of the physicians? No, I don't think so."

Many physicians may not be aware that they need to be accredited. "We are talking about hundreds of thousands of physicians who order this equipment across the board. Are they aware of everything?" Canally asks.